Artisan Contractor Insurance Quote Request

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ARTISAN CONTRACTOR INSURANCE QUOTE REQUEST
Complete the following information if you would like to obtain an Artisan Contractor Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?	Last
	First
	Middle
What is your business name?	Business Name
What is your address?	Street
	City
	State
	Zip
What is your telephone number?	Home
What is your telephone number?	Business
What is your fax number?	Fax
What is your email address?	Email
Underwriting Information
How many owners?	Number of Owners
How many employees?	Number of Employees
What is the payroll amount of the owners?	Payroll of Owners
What is the payroll amount of the employees?	Payroll of Employees
What is the total annual gross?	Total Annual Gross Receipts
What are the annual sub costs?	Total Annual Sub Costs
What is your classification?	Classification
What is your contractors license number?	Contractors License Number
What is the license type?	License Type
Years of experience in this business?	Years of Experience
How many years have you operated under your current business name?	Years Operated Under Current Name
Have you used any other business names during the past 5 years?	Other Business Names	Yes No
Have you been involved in the original construction or remodeling of town homes, condos, row homes or developments of 15 or more unattached single family dwellings during the past 5 years?	Construction or Remodeling	Yes No
Do you construct footings or foundations which may support dwellings or other structures?	Construct Foundations	Yes No
Do you construct slab or monolithic floors?	Construct Floors	Yes No
Do you construct piers or underpinning which may support dwellings or other structures?	Construct Piers	Yes No
Do you construct retaining walls which may support dwellings or other structures?	Retaining Walls
Do you construct fireplaces or chimneys?	Fireplaces or Chimneys
What is the percentage of work done as a General Contractor?	Percentage as General Contractor
What is the percentage of work done as a Sub-Contractor?	Percentage as Sub-Contractor
What is the percentage of work done on Residential?	Percentage on Residential
What is the percentage of work done on Commercial?	Percentage on Commercial
What is the percentage of work done for Remodeling?	Percentage on Remodeling
What is the percentage of work done for Renovation?	Percentage for Renovation
What is the percentage of work done for Repair or Maintenance?	Percentage for Repair or Maintenance
Claims Information
Where there any losses or claims in the last 5 years?	Losses - Claims	Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?	Amount Current Coverage
What is the liability limit requested?	Liability Limit
What is the loss of income requested?	Loss of Income Coverage
Are there any questions, comments or additional coverage required?	Questions, Comments or Additional Coverage

Best Time to Contact You
Please let us know the best time to call and discuss your quote.	Morning Afternoon Evening Anytime	Or specify other:


	V. H. JR., & ASSOCIATES, INC. 1435 W Busch Blvd. Ste. D \| Tampa, FL 33612 Phone 813-931-5546 Fax 813-931-9137

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